Gastrointestinal Internal Fistulas in Crohn’s Disease

Abstract

Case Summary: A 27-year-old man with fistulizing terminal ileal Crohn’s disease with an ileosigmoid fistula progressed through medical management and required an abdominal operation at an outside hospital. He underwent an ileocolic resection and a debridement with oversewing of his mesenteric sigmoid fistula with a diverting loop ileostomy. After a normal colonoscopy, his stoma was reversed; however, 2 weeks later he presented to the hospital with pelvic sepsis. A CT scan with oral, intravenous, and rectal contrast demonstrated a persistent sigmoid fistula with associated abscess. After treatment with antibiotics and percutaneous drainage, the patient underwent a segmental sigmoid resection to repair the mesenteric fistula and a diverting loop ileostomy. The ileostomy has been reversed and the patient’s Crohn’s disease is in remission.

Bowel Resection Margins in Crohn's Disease: Do They Matter?

“…If there is no healthy bowel bridging the proximal fistulae and the TI disease, or there is severe malnutrition with localized sepsis, then an extended resection including the proximal fistulae is warranted and may even result in using the proximal fistula as the diverting stoma or as an end stoma with a colonic mucous fistula. 43 The TI mesentery typically needs to be ligated with suture-ligatures (typically performed with overlapping, sequential Kocher clamps, ligated with horizontal, interlocking #1 sutures) as vessel sealing devices do not adequately control the friable mesentery and an expanding hematoma can be encountered (►Fig. 5).…”

“…If there is no healthy bowel bridging the proximal fistulae and the TI disease, or there is severe malnutrition with localized sepsis, then an extended resection including the proximal fistulae is warranted and may even result in using the proximal fistula as the diverting stoma or as an end stoma with a colonic mucous fistula. 43…”